Affordable health: Saving Kenyans from high costs

Makueni Governor Kivutha Kibwana, Dr Nelly Bosire and CAS Rashid Aman during the Nation Leadership Forum with the theme “Our Health, Our Future” at the University of Nairobi on July 5, 2018. PHOTO | DENNIS ONSONGO. 

You are one illness away from financial ruin”, or so the saying goes. And for three out of four Kenyans who are not covered by any health insurance, this saying rings all too true.

If they find themselves in the shoes of the one in five Kenyans who get sick every month, a fraction of them (16 per cent) fail to seek medical attention due to financial constraints. Another four out of 10 tough it out by selling their belongings or take loans to pay medical bills, but in the process, nearly a million or so are pushed into destitution by high healthcare costs.

For every hospital bill, Kenyans dig deep into their pockets to cover a huge chunk of it (a third).


Through the Big 4 Agenda announced by President Kenyatta last December, Kenya hopes to tackle the high-out-of-pocket costs by implementing Universal Health Coverage by 2022. The topic of universal health coverage took centre-stage at the recent Nation Leadership Forum, dubbed Our Health, Our Future, where thought leaders in the health space talked about Kenya’s journey to providing health for all.

Speaking at the forum, the World Health Organisation Country Representative for Kenya Rudi Eggers, explained that universal health coverage means that all people, not only in Kenya, but across the world, have access to basic health services that are of high quality, without suffering financial loss (or having to pay out of their own pockets for healthcare).

Central to universal coverage, according to the WHO, is access to a strong, efficient, well-run health system that meets the most important health needs of the communities it serves. That system must promote prevention of illness and healthy living, detect illnesses early and have capacity to treat them and rehabilitate patients. It must also be affordable, so that the people using it can do so without fear that they will run out of money.

It must provide essential medicines and technologies to diagnose and treat medical problems and employ a sufficient supply of well-trained and motivated health workers to provide services that meet the patients’ needs in the best way possible.

Also key to universal coverage, is access to health services in terms of geographical location (the recommended standard is that every person should live at least five kilometres from a health facility). However, as Dr Eggers noted during the Nation Leadership Forum, Kenya still has quite some distance to cover on this aspect.

“In many areas of the country, access to services still has to be built further, and not only the health facilities, but also health workers. It is very important that when you come to a health facility, there is a qualified and knowledgeable health worker who is able to treat you and has the means to refer patients to higher facilities if necessary; and has the right equipment,” he said during the forum.

In 2017, Kenya had 11,324 health facilities, but in some counties, residents still have to cover more than five kilometres on average to get to the nearest hospital. According to a report by the Kenya Institute of Public Policy Research and Analysis, 80 per cent of these health facilities are health centres and dispensaries which offer primary care, and 86 per cent have the basic medical equipment needed to provide general health services.

To meet the UHC goal by 2022, Kenya plans to scale up insurance coverage through the National Hospital Insurance Fund (NHIF), to reduce out-of-pocket costs from 26 per cent to 12 per cent in 2022. With this, the government hopes that Kenyans can be assured of treatment at minimal cost. This will mean boosting the number of NHIF principal members from the current six million to at least 13 million in five years.

But can Kenya really attain its lofty dream of Universal Health Coverage by 2022, eight years earlier than the global target of 2030?


Experts who convened for the fifth Nation Leadership Forum emphasised that in order to achieve the provision of quality care, there needs to be equity, rather than equality. According to Dr Githinji Gitahi, who serves as Amref Health Africa Group CEO and Co-chair of the UHC2030 steering committee, universal health coverage means that those left behind are brought to the same level as those who can afford to pay for health services. He added that Kenya needs to change how it purchases healthcare, to make it more strategic, thus reducing wastage.

“We all purchase healthcare individually by paying out of pocket when we are sick, but we need to be more strategic. The wastage in the system is because we lack a strategic approach to purchasing health. We need to ask: What do we need to purchase, from where and at how much to get value for money,” Dr Githinji said, giving an analogy of a parent who pays each teacher individually to educate his child, versus parents who pay together for one teacher who provides education collectively to many children.

To achieve UHC however, he added, there must be political will and adequate allocation of resources, something that the government is yet to do.

“The country’s current budgetary allocation for healthcare is well below the Abuja Declaration of 15 per cent. Contrary to the current allocation of Sh4,000, to achieve Universal Health Coverage, we estimate that we need to allocate Sh9,000 per person annually. That means the government must step up its game,” he said at the Leadership Forum.

Makueni Governor Kivutha Kibwana, who has been able to implement a form of universal coverage in his county explained that all it took was doing the math.

“It’s actually very simple. We did the math: How many people come to pay in hospitals and how much do they pay? Suppose we take the 162,000 households and divide the amount? We found that if every household paid Sh500, we would be able to get the money that everybody pays when they come to our facilities. Through that we have 70 per cent coverage,” he said.

Beyond financing, the panellists noted that the government would have to ensure that health facilities have the requisite personnel and equipment to make quality health for all a reality. Access to the services and resources, availability of adequate and highly trained human resource and proper infrastructure are some of the key things that the experts advised the government to focus on.

“Our doctors are good and able. We just need to put resources in place, so that they are able to work. And so that we don’t get brain drain to the private sector, or more lucrative areas to other countries,” noted Dr Kahaki Kimani, an ophthalmologist and senior lecturer on the panel. She added that the entire human resource system from top to bottom should work to ensure a cohesive system that could deliver the services needed.

Already, the government has planned to pilot the UHC programme before national adoption. Four out of 47 counties were selected for the pilot, with Kisumu, Isiolo, Nyeri and Machakos being used as samples to generate the required feedback expected to guide a countrywide rollout. A sample size in the rest of the 43 counties will be 10,000 households, the Health Ministry had earlier announced and confirmed the news last week.


Some experts however feel that more needs to be done to not only assure the success of universal health coverage but to also make it affordable.

Dr Nelly Bosire, a gynaecologist and obstetrician and one of the panellists opined that to achieve Universal Health Coverage, the country needs to make good use of hundreds of medical officers it trains annually, instead of putting so much emphasis on specialists.

“We must understand that UHC is not driven by specialists. It is driven by general practitioners (GPs), who do the bulk of the work of reviewing the patient, diagnosing them, treating and making the differentiation on whether the patient needs referral or not. The GP offers a general package, one of the driving pillars of UHC,” she said.

To create the necessary resources for healthcare, Dr Bosire said that the government ought to curb wastage.

“Our resources in healthcare are already quite limited. That means we cannot afford to channel resources which are not necessary. The Managed Equipment Services is one example of major wastage, whereby for the last four years counties have been paying for a service they have not been using,” she said.

However, Chairman of the Kenya Healthcare Federation Dr Amit Thakker, noted that despite the urgency, UHC should be seen as a process, rather than as an event.

“It is also important to note that the whole idea of UHC is not anchored on shutting down any system, be it public or private facilities, but an ideology enshrined on partnerships and inclusivity to offer the next generation a better health system tomorrow than what we have today.”

Dr Thakker further added that the country should not solely depend on the National Health Insurance Fund (NHIF).

The panellists also noted that citizens should be empowered and informed to actively engage in healthcare decisions and in designing new models of care to meet the needs of their local communities.

“Having doctors or the necessary infrastructure is not enough. Makueni’s success comes from the awareness that they needed to invest in the infrastructure, bring on board the human resource and finally ensured a constant supply of the needed resources. If I have NHIF, visit my local hospital and I’m told to buy the drugs outside because the hospital has run out of its supplies I will feel robbed,” said Dr Bosire.

Key takeaways:

1. Focus on retaining health workers trained in the country.

2. Purchase healthcare in a strategic manner to avoid waste. Ask what do we want to purchase, how do we purchase it, and who do we purchase it from? To get more value for money.

3. Put resources in place to enable doctors and other health professionals to work and to prevent brain drain.

4. Focus on general practitioners who offer primary healthcare even as specialists are emphasised.

5. In many parts of the country, access to health services needs to be built further to boost access to facilities and qualified health workers.

6. Deploy an army of tech-savvy community health workers and integrate them into health system for universal coverage to be a success from the grassroots.

7. Focus on preventive health (immunisation, prevention of waterborne diseases, HIV, TB, and improved maternal and child health, nutrition and behaviour change).

8. NHIF is a principal player in delivering universal health coverage, but needs drastic reforms.